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SAN JOAQUIN LOCAL'=IdkLTH 'DISTRICT <br /> FOF4iOFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> I Telephone: (209) 466-6781 <br /> APP IG)ATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. �7_ <br /> THIS PERMIT EXPIRES 1 -YEAR FROFi:DATE ISSUED Date Issued <br /> I (Complete In .Triplieate) <br /> Application is hereby made to the San Joaquin 'Local Health District for a permit to construct <br /> and/or install the work herein described. This application is made in compliance with San Joaquin <br /> County Ordinance Na. j1862 'and the .Rul.es and Regulations 'of-rhe. San Joaquin Local Health District. <br /> LOCATI <br /> JOB ADDRESS <br /> / ON 11 CENSUS TRACT <br /> Owner s s Name � ``. .� ;�x _- - .- <br /> � Phone <br /> Address 5rb <br /> R _�.:_...r <br /> City 13CL <br /> �S <br /> Contractor's Name �J �7 <br /> " '"'� �;R,•+c L"cs _ License Phone <br /> TYPE OF WORK1 a <br /> (Check) • NEW WELL /7 DEEPEN /? RECONDITION /-7 DESTRUCTION /_7 <br /> PUMP INSTALLATION PUAH' REPAIR /7 PUMP REPLACEMENT /? <br /> Other /T —.- <br /> i <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPER t LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTTC <br /> INTENDED USE W.T.T.TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> `Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private - Drilled Dia: of Well Casing <br /> Domestic/public Driven Dia.. <br /> w. _ , �...... .. <br /> rrigation x '# GravelyPadk ��. Depth_of ,Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> _Disposal i Other Other Information <br /> Geophysical t '' " Surface Seal Installed B <br /> PUMP INSTALLATION: Contractor , <br /> Type of Pump <br /> 00. <br /> P. _ q p <br /> PUMP REPLACEMENT: / f/ State Work Done <br /> PUMP .REPAIR: a` ork-Done. <br /> -stat-�w <br /> ES;TRUCTIONOF WELL: Well ^Diameter <br /> Describe Material and Procedure s Approximate Depth <br /> I hereby agree to comply with all laws and regulations of the San Joaquin Local Health District <br /> and the State of California pertaining to or -regulating well construction. Within FIFTEEN DAYS <br /> after completion of my work onia new well,. I will furnish the San Joaquin Local Health District a <br /> WELL 'DRILLERS REPORT of the- well and notify them before putting-the- well in-use.. The above <br /> information is true to the-best <br /> PRIOR TO GROUTING AND A FINAL INSPECTIONof my .knowledge and belief. ' I WILL CALL FOR A GROUT INSPECTION <br /> . <br /> SIGNED ! TITLE sL <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I. <br /> APPLICATION ACCEPTED BY <br /> ADDITIONAL COMMENTS: DATE �..� <br /> PHASE II GROUT INSPECTION P S I NAL INSPECTIO <br /> INSPECTION BY. DATE INSPECTION- BY DATE <br /> ell <br /> E H 1426 Rev. 1-74 <br />